Online Employment Application - American Care Employment Portal

Date of Application

How did you hear about us?

Position Applying for

Job Description

Location

Are you willing to relocate to another location?

Have you ever applied with American Care?

Work History

Employer's Name

Position

Immediate Supervisor's Name

Telephone

Currently employed (present employer)

Yes No

Start Date

End Date

Summarize the type of work performed and job responsibilities

Why did you leave?

Address

Employer's Name

Position

Immediate Supervisor's Name

Telephone

Currently employed (present employer)

Yes No

Start Date

End Date

Summarize the type of work performed and job responsibilities

Why did you leave?

Address

Employer's Name

Position

Immediate Supervisor's Name

Telephone

Currently employed (present employer)

Yes No

Start Date

End Date

Summarize the type of work performed and job responsibilities

Why did you leave?

Address

Employer's Name

Position

Immediate Supervisor's Name

Telephone

Currently employed (present employer)

Yes No

Start Date

End Date

Summarize the type of work performed and job responsibilities

Why did you leave?

Address

Employer's Name

Position

Immediate Supervisor's Name

Telephone

Currently employed (present employer)

Yes No

Start Date

End Date

Summarize the type of work performed and job responsibilities

Why did you leave?

Address

Education and Certification

Education Information

School Name

Location

Dates Attended

Start Date

End Date

Education Information

School Name

Location

Dates Attended

Start Date

End Date

Education Information

School Name

Location

Dates Attended

Start Date

End Date

Education Information

School Name

Location

Dates Attended

Start Date

End Date

Education Information

School Name

Location

Dates Attended

Start Date

End Date

Certification Information

Certification

Type of certification

School

Date certification was attained

Certification Information

Certification

Type of certification

School

Date certification was attained

Certification Information

Certification

Type of certification

School

Date certification was attained

Certification Information

Certification

Type of certification

School

Date certification was attained

Certification Information

Certification

Type of certification

School

Date certification was attained

IV. Skills And Proficiency Levels

Software Knowledge/Computer Skills

	Beginner	Intermediate	Advanced	N/A
Microsoft Excel
Microsoft PowerPoint
Microsoft Word
Quickbooks
Electronic Calendaring
Internet Navigation & Research
Other Software
Name of Other Software Mentioned Above

Technical Skills

	Beginner	Intermediate	Advanced	N/A
Word-Processing Speed
Shorthand Speed

Languages

Bilingual

Yes No

Language	Proficiency Level
English
Spanish
Creole
French
Portuguese

Professional / Employment References

List names and telephone numbers of three professional / employment references who are not related to you.

Reference 1

Name

Title

Telephone

Reference 2

Name

Title

Telephone

Reference 3

Name

Title

Telephone

VI. Application Statement & Acknowledgments

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Applicant Statement

I certify that all information I have provided in order to apply for and secure work with American Care is true, complete, and correct.

I understand that any information provided by me that is found to be false, incomplete, or misrepresented in any respect, will be sufficient cause to (i) cancel further consideration of this application, or (ii) immediately discharge me from American Care’s service, whenever it is discovered.

I expressly authorize, without reservation, American Care, its representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume or job interview. I hereby waive any and all rights and claims I have regarding the employer, its agents, employees or representatives, for seeking, gathering and using such information in the employment process and all other persons, corporations or organizations for furnishing such information about me.

I understand that the employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant from consideration for employment on a basis prohibited by applicable local, state to federal law.

If I am hired, I understand that I am free to resign at any time, with or without cause and without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no supervisor or representative of the employer is authorized to make any assurances to the contrary and that no implied oral or written agreement contrary to the foregoing express language are valid unless they are writing and signed by the employer’s president

I also understand that if I am hired, I will be required to provide proof of identity and legal authority to work in the United States and that federal immigration laws require me to complete an I-9 form in this regard.

I understand that any information provided by me that is found to be false, incomplete, or misrepresented in any respect, will be sufficient cause to (i) cancel further consideration for employment, or (ii) immediately discharge me from the employer’s service, whenever it is discovered.

Electronic Signature Authorization. By checking this box, I acknowledge that the electronic submittal of this application is the same as submitting a signed application. I further certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement and all information is true and accurate.

Print Name

Date

Minimum Proficiency	Ability to speak the language with sufficient accuracy and vocabulary to participate effectively formal and informal conversations on practical, social, and professional topics.	Ability to read newspaper items addressed to the general reader, every day correspondence, reports, and technical materials.
Full Proficiency	Ability to use the language fluently and accurately on all professional levels.	Able to read all styles and forms of the language pertinent to professional needs.
Native or Bilingual Proficiency	Equivalent to an educated native speaker.	Equivalent an educated native.